Disability and Insurance Claims in Primary Care: Documenting a Diagnosis

Text adapted from: "Disability and insurance claims in primary care," in Psychiatry in primary care  by Ash Bender (CAMH, 2019).

Documenting a Diagnosis: Symptoms and Functioning

Physicians are trained to identify symptoms in a clinical setting and to obtain a diagnosis. Currently, the insurance system in Canada has transitioned from the DSM-IV multi-axial system to the DSM-5 as the standard. This requires the physician to provide supporting symptoms for each diagnosis. If clinicians are using the Global Assessment of Functioning (GAF), which is not found in DSM-5, people experiencing total disability due to mental illness are expected to have a GAF score of 50 or lower, reflecting severe impairment. The WHO Disability Assessment Schedule 2.0 (WHODAS) is another helpful tool for assessing degree of functional impairment due to physical and mental conditions (WHO, 2010).

Assessing functioning is critical for determining whether a symptom is causing functional problems. See Table 1 for examples of psychiatric symptoms and possible corresponding areas of problematic workplace and interpersonal functioning.

A specific diagnosis may affect people differently, depending on the type of symptoms and specific job duties. Here are examples: major depressive disorder:

• fatigue
• cognitive problems
• uncontrollable tearfulness
• panic disorder:
• poor stress tolerance
• agoraphobia
• posttraumatic stress disorder:
• triggered anxiety and anger
• avoidance of trauma reminders

Symptoms and associated functional impairment in the workplace

Symptoms: Irritability, sadness, anxiety, anhedonia, suicidal ideation, delusions, poor concentration or memory problems, executive dysfunction, sleep changes, poor energy,  intoxication.

Functional Impairments: Conflict, unexpected emotional reactions, avoidance, poor motivation, low engagement, high-risk behaviour, decreased efficiency, increased errors, poor decision making, self restricted activities, neglect of home and work duties, violence and accidents.

Asking about functioning will clarify the diagnosis and help to assess the patient’s current capacity to work (see Table 2).

Taking a Functional History

• Is the person able to work in his or her regular role or any capacity?
• What are the limitations and restrictions?
• What are the suggested accommodations?

When inquiring about the nature of the patient’s work, be sure to determine:

• physical demands
• emotional demands
• cognitive demands
• requirements to manage conflict
• safety-sensitive duties 
• individual and team responsibilities
• relations with customers, co-workers and employer
• shift schedule
• travel requirements

Such specific inquiries about the nature of the patient’s work are very important, but are often missed. Getting this information will strengthen your recommendations for restrictions and suggested accommodation. Total disability arises only when duties cannot be modified to accommodate the impairment.

Table 2 - Taking a Functional History 

In Disability and Insurance Claims in Primary Care

• Overview
• Key Definitions
• Documentation and claims
• Documenting a Diagnosis
  •  Planning and providing rehabilitation-focused treatment
• Facilitating the patient's return to work
  • Communicating with Employers
• Resources and References